"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

March 02, 2015

The Khyber-Pakhtunkhwa government proved its determination to eradicate polio by arresting 471 parents who refused vaccine for their children, while authorities have also hired religious scholars to convince families.

The offenders were taken into custody on Monday under Section 3 of the Maintenance of Public Order.

Police said the arrests were ordered by DC Peshawar as polio workers reported those parents who refused oral polio vaccine drops for their children during the campaign last week.

“Arrests have been made in the jurisdictions of Mathra, Mattani, Khazana and Sarband police stations,” a police official told The Express Tribune. More will be taken into custody to force them to vaccinate their children,” he added.

The DC Peshawar’s spokesperson, Jamil Shah, confirmed the detained parents refused to vaccinate their children below five years of age. So far, all those arrested have been sent to Central Jail Peshawar. The spokesman added the civil administration issued warrants to arrest another 1,000 parents and directed police to take them into custody at the earliest.

Shah added such extreme measures were taken to rid the province of polio, a disease that is putting “Pakistan’s image at stake around the globe”.

By the book

The K-P health department sent “religious support persons” to convince parents refusing polio vaccination under Sehat ka Ittehad, a joint venture of the provincial and federal governments.

“These individuals will not be travelling with polio vaccinators from door-to-door,” a health official said, requesting anonymity. “Their job begins when someone refuses to vaccinate their children.”

He said parents were usually convinced when approached by religious scholars. However, those houses that refused were pinpointed and that was when the police department also got involved.

“Our aim is to administer polio drops to children at all cost, whether it is through the influence of religious personalities, local elites or the force of the police,” he said.

PESHAWAR, Pakistan — Determined to curb Pakistan’s polio crisis, police officials in the northwestern province of Khyber-Pakhtunkhwa said Friday that they had issued hundreds of arrest warrants for parents for refusing to vaccinate their children.

“We had 13,000 to 16,000 refusal cases,” the deputy police commissioner for Peshawar, Riaz Khan Mahsud, said in an interview. “There is total determination on our part. We shall convince parents of the good of vaccinating their children, but if they refuse, we shall detain them. There is no leniency.”

The police in other districts of the province also reported issuing warrants, though no official total was released.

“The number keeps fluctuating,” said a senior government official, speaking on the condition of anonymity because he was not authorized to brief the news media. “We are applying different laws. You have to resort to coercive measures when persuasion fails.”

The official added: “The application of laws is working. Some parents readily agree to vaccinate children to avoid detention. Others take a few days behind the bars to see reason. We take an affidavit from them and let them go if they bring kids for vaccination.”

Last year, 306 new polio cases were reported in Pakistan, breaking the country’s previous record high of 199 new cases in 2000.

“This was due to complacency and a very bad security situation,” said Dr. Imtiaz Ali Shah, head of the government’s polio monitoring group in Khyber-Pakhtunkhwa.

Dr. Shah said the outbreak was particularly bad in two northwestern tribal regions, North and South Waziristan, remote areas that have been havens for militants from Al Qaeda and the Taliban and their allies, making them mostly inaccessible to vaccination teams. Then, in June, the military began an offensive in North Waziristan to root out the militants, sending hundreds of thousands of refugees into the rest of Pakistan and across the border into Afghanistan.

The refugees “took the virus with them everywhere they went — in K.P., Baluchistan and Sindh,” Dr. Shah added. “There was a Ping-Pong, cases popping up here, cases popping up there.”

Despite this, Dr. Shah said the military operation had given officials the best chance in years for polio teams to make progress in the tribal areas.

February 26, 2015

Thanks to Irene L for tweeting the link to this important post at International SOS Ebola: comments on Ebola as an aerosol virus by Professor John Oxford. Excerpt:

A key virological fact to remember here is that we are dealing with vast populations of Ebola as much as 10 million viruses per micro drop of diarrhoea. These early observations have been well confirmed in the current outbreak. Of necessity with this way of spreading then the number of cases in the community will remain very low and the chain of infection will be easily broken by quarantine of suspects, training of medical staff in Personal Protective Equipment (PPE), good hygiene and a ‘no touch’ technique at funerals of victims and in the community. Evidence from most outbreaks as well as the present one amply confirms this.

As regards the numerical issue, we have to date around 21,000 cases in 12 months in a population of 30 million or so in the countries involved. These are relatively low numbers indeed and do not speak to us of aerosol or air droplet spread.

To give a contrary example of droplets and aerosol spread, in the last week a cornucopia of respiratory viruses have struck in the UK such as influenza, RSV and adenovirus, all spread mainly in the airborne manner and 100,000 persons have been infected over those few days.

I also want to widen the context to other viruses to illustrate that under very special circumstances these minute viruses can take advantage of a unique or unexpected opportunity to spread. We all know that hepatitis B is at a relatively high level in Africa and is spread by sex, blood and birth.

But in an overcrowded family household with lots sharing of towels, toothbrushes and shaving kits, even in the observed absence of blood, the virus can spread. This happens in the UK as well. The reason? The virus, like Ebola, is present in the victim in exceedingly high numbers of greater than 10 million viruses per micro drop of blood.

We never begin to speculate with hepatitis B that it could be spread by coughing, although I have little doubt that amongst the 200 million or so carriers in the world such a transmission has occurred! The virus would certainly be present in mouths with poor tooth hygiene.

Even more relevant is polio. The spread here is faecal/oral via sewage contaminated rivers, swimming pools or, in the family, by poor hand hygiene. But many of the early studies with the live attenuated polio vaccines described the presence of polio virus in saliva from the throat. So again we have well established and documented manner of spreading of a virus by the faecal/oral route, but it is never thought that polio could be spread by coughs and sneezes.

As a final illustration of the ‘just possible’ is rotavirus. This important diarrhoea virus, which incidentally would be expected to have killed more children in West Africa during the last year, compared to Ebola, is again present in stools in exceedingly high quantities. So should a mother casually throw a diarrhoea nappy [diaper] onto the table a few virus particles could spray out as droplets and it is possible that these could be breathed in.

As regards the ‘catch all’ that RNA viruses can mutate, most they do not and the exceptions are influenza and HIV. Polio, rubella, measles, mumps to name a few have not changed in 60 years and Ebola is the same.

Post peak infection curves of the virus always carry a danger

The curve of acquisition of new cases of Ebola, along with figures of death, had peaked in Liberia and Guinea before Christmas: shortly before the arrival of many international groups. This does not mean that their help was unneeded. The contrary is definitely the case. The withdrawal of these trained medical and nursing staff at this precise moment would not be helpful.

The downward running curve of Ebola cases is exceedingly dangerous for two reasons. Firstly the medical staff will be refocused on the other infections in West Africa, malaria, Lassa fever, cholera and enteric pathogens and TB. The declining Ebola cases will make them more easy to miss.

Even more important, these communities themselves will begin to relax and touching and kissing, and funeral habits will start up again.

It took one year to go from one case to 21,000 but now we are not at ground zero with the number of persons currently infected and so outbreaks could start up again from figures way above one! West Africa needs our scientific and medical help for at least the next 6 months and thereafter to train staff for the next outbreak.

Dr. Oxford concludes by writing: "...what these three West African countries really need is international help to build safe water system, sewage, and a health service with well trained doctors and nurses fit for the 21st century. Is this beyond the pale in a world where 500 young people in Europe have volunteered in the last few days to go to Mars on a one way ticket?"

In the spring of 2010, the U.S. Central Intelligence Agency's (CIA) search for bin Laden began to focus on a certain villa in Abbottabad, a garrison town in the Himalayan foothills of Pakistan. A mystery man was shuttered away on the villa's top floor. CIA agents suspected it might be bin Laden, but they needed to be sure before launching a raid. So they devised an imaginative plan to identify him.

Operatives would hire a Pakistani doctor and nurses to conduct a door-to-door hepatitis B vaccination campaign in the neighborhood. After the children who lived at the villa were immunized, DNA from the used syringes would be analyzed to determine whether they were related to bin Laden.

The Pakistani health official approached by CIA operatives was Dr. Shakil Afridi. Tall and stout, with a cropped mustache that gave him a military bearing, Afridi had the right credentials from the CIA's perspective. He was a Pashtun and spoke the local language, Pashto. He had conducted a successful vaccination campaign near the Khyber Pass, in northwestern Pakistan. He had lived in California for several months and had family in the United States.

The doctor says that he never knew he was working for the CIA and that he was approached by a local representative of Save the Children, who asked him to run the vaccination campaign. (Save the Children denies having any connection with the CIA or any intelligence agency, or having any role in the subterfuge.)

Either way, the offer of the equivalent of $12,500 (U.S.) to organize and administer the vaccinations came at a moment when the doctor was short on cash.

Earlier, Afridi had been kidnapped and held for ransom by Lashkar-e-Islam, an extremist militia outlawed in Pakistan. The group's commander claimed that he'd heard rumors the doctor was overcharging patients in his private clinic. Afridi's family denied the allegations but paid a $10,000 ransom. According to Afridi's attorney, the Lashkar-e-Islam commander pocketed half and distributed the rest to the patients that Afridi allegedly had overcharged.

The CIA's vaccination ploy didn't work exactly as planned.

When Afridi banged on the Abbottabad villa's huge metal gate, a woman answered and refused to allow the children inside to be vaccinated. Stubbornly, Afridi demanded the cell phone number of the man of the house so that he could possibly arrange for the children to be vaccinated at a later date.

This cell phone number proved to be a vital piece of information to his handlers. It belonged to Ibrahim Saeed Ahmed, who turned out to be bin Laden's guardian and messenger. The CIA knew of his existence but had never located him. Ahmed was the al Qaeda leader's sole link to the world outside the villa's 20-foot-high (6-meter) walls.

Chasing down the lead from that phone number would lead to a major coup in the U.S.-led war on terrorism, but it also would set back the war on polio.

February 19, 2015

Four members of a polio immunization team have been found murdered after being kidnapped in southwest Pakistan, officials said Wednesday.

Local militants had abducted the vaccination worker, two local tribal policemen and a driver in the Zhob district of Baluchistan province on Saturday. Pakistan is one of only three countries where polio remains endemic. But attempts to eradicate it have been badly hit by opposition from militants and attacks on immunization teams that have now claimed 71 lives since December 2012.

“Security agencies conducted several operations to recover the polio worker and other team members and finally found their bodies in the mountains on Tuesday,” a senior local administration official in Zhob, Nazar Muhammad Khatran, told AFP.

He said it seemed the four men were shot dead on Saturday or Sunday.

A spokesman for the paramilitary Frontier Corps, Manzoor Ahmad, confirmed the incident. Taliban militants claim that the polio vaccination drive is a front for espionage or a conspiracy to sterilise Muslims. They stepped up their attacks after a Pakistani doctor was recruited by the CIA to take part in a fake immunisation drive to capture Osama Bin Laden.

Ahmad said Frontier Corps troops on Wednesday secured the safe release of five field staff from the Pakistan Telecommunication Company after an exchange of fire with militants in Zhob district. They had been abducted last week.

Apart from attacks on vaccination teams, Baluchistan - Pakistan’s largest but least developed and most sparsely populated province - has been racked for decades by a separatist insurgency that was revived in 2004.

February 17, 2015

Ineffective homeopathic alternatives to vaccines should be taken off the market because they are a dangerous distraction, public health officials urge as infectious diseases such as measles make a comeback.

Some naturopaths, homeopaths and chiropractors sell homeopathic nosodes described as a diluted remedy of bacteria or virus. They are most often given orally, but can be injected as well.

Health Canada says the packages need to be labelled with a warning: "This product is not intended to be an alternative to vaccination."

Last year, CBC-TV's Marketplace found homeopathic practitioners telling parents nosodes were as effective as vaccines against diseases such as measles, polio and pertussis (whooping cough), which is highly contagious and can be fatal for infants.

"There's no evidence to support their claims at all around providing immunity against infectious diseases," said Dr. Robert Strang, Nova Scotia’s chief public health officer. "I think, frankly, having them available on the market is dangerous. It's distracting and it's helping people avoid immunization or giving them a reason not to be immunized."

Strang said in 2013 his provincial and territorial colleagues wrote to Health Canada to request nosodes be pulled from the market. He repeated his call on Tuesday.

"Those warning labels really aren't having an impact," Strang said.

In Ontario, where 16 cases of measles have been identified, Ontario health minister Dr. Eric Hoskins said vaccination is the only way to protect yourself and those around you from the highly infectious disease.

"There's no such thing as a homeopathic or a naturopathic vaccine," Hoskins said. "The only way you can protect yourself is by being vaccinated. So it does worry me anytime that there is misinformation out there in the public domain."

February 14, 2015

Gunmen attacked a vehicle carrying a polio vaccination team in northwestern Pakistan on Saturday, killing the driver and wounding a health care worker, according to police officials.

The attack took place in the restive Khyber tribal region, which straddles the border with Afghanistan and has been the site of a recent offensive by the Pakistani military. There was no immediate claim of responsibility for the attack, but polio vaccination workers are frequently singled out across Pakistan by Taliban militants, who view the campaign as un-Islamic and the health workers as Western spies.

Separately on Saturday, two polio workers and two security guards were reported to have gone missing in the southwestern province of Baluchistan, officials said. It was not immediately clear whether they had come under attack or had merely fallen out of contact in the remote area where they were working.

“There is no proper communication system, which is why we are facing difficulty in tracing them,” a news report quoted a provincial official, Nazir Ahmed Khetran, as saying.

February 04, 2015

Via The New Yorker, a fascinating parallel: When Ike Trusted a New Vaccine. After describing the dread polio once instilled on Americans, the article continues:

Sixty years ago, the idea that the federal government might launch a giant program to vaccinate millions of people—for their own protection, and not least to protect others from infection—seemed the height of rationality, an understanding that the best medicine is preventive medicine. This view prevailed despite a truly ghastly mistake in the early days of the program, during the Salk vaccine’s first trial, with 1.8 million children.

Licenses to produce the vaccine had been granted with great speed to five pharmaceutical firms, but one of them, Cutter Laboratories, of Berkeley, California, had been careless. Cutter produced a vaccine that contained live polio virus, an error that directly led to five deaths and fifty-one cases of permanent paralysis, and that in turn led to a small epidemic: the Cutter group’s infection spread to friends and neighbors; five more died and more than a hundred family members or neighbors were paralyzed.

Recounting this in the New England Journal of Medicine, in 2005, Dr. Paul A. Offit, who later wrote a book about the Cutter incident and its aftermath, described how, despite what he rightly called “one of the worst pharmaceutical disasters in U.S. history,” the program continued, first with the Salk vaccine and then with an effective oral vaccine developed by a medical rival, Albert Sabin.

But there was very little posturing from the Democratic Congress about the Cutter incident. A House of Representatives committee said that it would look into the Administration’s handling of the program and safety; there were calls for Oveta Culp Hobby, the H.E.W. secretary, to resign. Eisenhower, whose temperament was the opposite of panicky, held a press conference in early May and said that he expected to see a report “covering every single detail, factual and planning detail, of the whole matter. As quickly as I get it, I will make it available to the public.”

But the program was in no danger of stopping, and money wasn’t going to get in the way. “I want to emphasize again that the matter of inability to pay is never going to have the slightest thing to do with this, and that it is going to be distributed equitably to every state in the union,” the President said.

Still, no one could guarantee that the vaccine was absolutely safe; Offit pointed out that the licensing procedure took just two and a half hours. (The process today is, needless to say, far more extensive.)

But if anyone doubted what Salk and Sabin and all who came before them had achieved, the statistics were persuasive: the number of polio cases dropped from thirty-eight thousand, in 1954, to twenty-nine thousand, in 1955—and, a year later, to fifteen thousand. Since then, polio has pretty much been wiped out in the United States and most of the world. So have what were once fairly common “childhood diseases”—measles, mumps, and rubella, among others. Or so it was thought.

Measles and the rest, although they can cause death and misery, never did the damage that polio did, which may be why it’s so easy for some public figures to dilate so irresponsibly on the subject. Chris Christie, the governor of New Jersey and world traveller, visited a vaccine laboratory in Cambridge, England, the other day and said that there should be some “some measure of choice” as to whether shots for measles and other diseases should be mandatory—in other words, let your infectious children roam at will.

Rand Paul, the Kentucky senator and a doctor, went on a couple of television programs and said that most vaccines should be voluntary, to help avoid the risk of “many tragic cases of walking, talking, normal children who wound up with profound mental disorders after vaccines.”

Read the whole article; it brought back a lot of memories to this polio survivor.

February 03, 2015

As the US is gripped by a raging and increasingly politicised debate about the wisdom or otherwise of vaccinating children against measles and other diseases, there has been some positive news from a unlikely quarter.

A report by the Integrated Regional Information Networks (IRIN) news agency reveals that Isis militants have been granting access to anti-polio vaccination teams in areas they control.

The global battle against polio has largely been a success. India, which once accounted for half of the world’s cases of polio, was taken off the endemic list in 2012 after a massive public health campaign. Today, polio remains endemic in just three countries - Pakistan, Nigeria and Afghanistan.

But in October 2013, it was reported that more than 20 new cases of polio had been identified in Syria. The spread of the disease has been aided by the breakdown in healthcare infrastructure and vaccination programmes as Syria suffered more and more from the effects of the civil war.

World Health Organisation officials later identified that the strain of the polio virus n that had broken out in Syria had originated in north-west Pakistan, where public health campaigners are involved in an ongoing battle to persuade communities to get their children vaccinated.

The Pakistan Taliban has come out against the programme and regularly attacked polio vaccination teams. There is widespread suspicion of the vaccination teams and many people believe conspiracy theories that claim the workers are part of a Western-backed plot to sterilise Muslims.

Such suspicion grew in the aftermath of the US operation to kill Osama bin Laden when it was revealed that the CIA had recruited a Pakistani doctor to establish a fake vaccination campaign in an attempt to obtain a DNA sample from youngsters in the al-Qaeda leader's Abbottabad compound.

The IRIN report, highlighted by Vox, says Isis fighters in Syria have been more amenable to the programme and says while areas controlled by the militants have been largely inaccessible to international aid interventions, the Polio Task Force in Syria, led by the Syrian opposition’s humanitarian aid arm, was permitted to carry out immunisation campaigns there.

“There was a general level of acceptance and demand by the local population [for the vaccinations]. It would have been difficult for IS not to allow it,” a director of an international aid organisation working in Syria told IRIN.

February 01, 2015

PESHAWAR: Authorities in Khyber Pakhtunkhwa has imposed a ban on motorcycle riding in the provincial capital as part of security arrangements for the anti-polio drive that started today (Sunday).

The ban has been imposed under section 144 as the provincial capital plans to administer polio vaccine to 700,000 children.

According to the health department, 4000 teams of volunteers have been formed to complete the task of administering the vaccine while policemen have also been deployed for the security of the health workers.

The department said that due to emerging polio cases and people’s refusal to get their children vaccinated, WHO officials were also busy in counseling of the parents to persuade them.